Adrienne Testa

Background
Populations affected by crises (armed conflict, food insecurity, natural disasters) are poorly covered by demographic surveillance. As such, crisis-wide estimation of population mortality is extremely challenging, resulting in a lack of evidence to inform humanitarian response and conflict resolution.

Methods
We describe here a ‘small-area estimation’ method to circumvent these data gaps and quantify both total and excess (i.e. crisis-attributable) death rates and tolls,… Show more

Background
Populations affected by crises (armed conflict, food insecurity, natural disasters) are poorly covered by demographic surveillance. As such, crisis-wide estimation of population mortality is extremely challenging, resulting in a lack of evidence to inform humanitarian response and conflict resolution.

Methods
We describe here a ‘small-area estimation’ method to circumvent these data gaps and quantify both total and excess (i.e. crisis-attributable) death rates and tolls, both overall and for granular geographic (e.g. district) and time (e.g. month) strata. The method is based on analysis of data previously collected by national and humanitarian actors, including ground survey observations of mortality, displacement-adjusted population denominators and datasets of variables that may predict the death rate. We describe the six sequential steps required for the method’s implementation and illustrate its recent application in Somalia, South Sudan and northeast Nigeria, based on a generic set of analysis scripts.

Results
Descriptive analysis of ground survey data reveals informative patterns, e.g. concerning the contribution of injuries to overall mortality, or household net migration. Despite some data sparsity, for each crisis that we have applied the method to thus far, available predictor data allow the specification of reasonably predictive mixed effects models of crude and under 5 years death rate, validated using cross-validation. Assumptions about values of the predictors in the absence of a crisis provide counterfactual and excess mortality estimates.

Conclusions
The method enables retrospective estimation of crisis-attributable mortality with considerable geographic and period stratification, and can therefore contribute to better understanding and historical memorialisation of the public health effects of crises. We discuss key limitations and areas for further development. Show less

The conflict in South Sudan has likely led to nearly 400,000 excess deaths in the country’s population since it began in 2013, with around half of the lives lost estimated to be through violence, according to a major new report by the London School of Hygiene & Tropical Medicine. Most of the death toll occurred in the northeast and southern regions of the country, and appeared to peak in 2016 and 2017. Those killed were mostly adult males but also included women and children. Unexpectedly, the… Show more

The conflict in South Sudan has likely led to nearly 400,000 excess deaths in the country’s population since it began in 2013, with around half of the lives lost estimated to be through violence, according to a major new report by the London School of Hygiene & Tropical Medicine. Most of the death toll occurred in the northeast and southern regions of the country, and appeared to peak in 2016 and 2017. Those killed were mostly adult males but also included women and children. Unexpectedly, the share of infant mortality was low, and estimates of the under-five death rate were no higher during the war period than before it.

The authors say the findings indicate that the humanitarian response in South Sudan must be strengthened, and that all parties should seek urgent conflict resolution. The research team used an innovative statistical approach to predict deaths which were attributable to crisis for every month and county of the period of interest, and say this approach has the potential to support those involved in humanitarian response and policy to make real-time decisions. Show less

With 1 billion people on the move globally—more than 244 million of whom have crossed international borders—and a recognised need to strengthen efforts towards universal health coverage, developing a better understanding of how to respond to the complex interactions between migration, mobility, and health is vital. At the 2nd Global Consultation on Migrant Health in Sri Lanka earlier this year, a group of global experts in health and migration discussed the progress and shortfalls in attaining… Show more

With 1 billion people on the move globally—more than 244 million of whom have crossed international borders—and a recognised need to strengthen efforts towards universal health coverage, developing a better understanding of how to respond to the complex interactions between migration, mobility, and health is vital. At the 2nd Global Consultation on Migrant Health in Sri Lanka earlier this year, a group of global experts in health and migration discussed the progress and shortfalls in attaining the actions set out in the 2008 World Health Assembly Resolution on the Health of Migrants. Show less

All women should have access to high quality maternity services—but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take… Show more

All women should have access to high quality maternity services—but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place. The necessity of ascertaining actual facility capability and providers' skills is highlighted, as is the paucity of information on maternity waiting homes and transport as mechanisms to link women to care. Furthermore, we stress the importance of assessment of routine provision of care (not just emergency care), and contextualise this importance within geographic circumstances (eg, in sparsely-populated regions vs dense urban areas). Although no single model-of-care fits all contexts, we discuss implications of the models we observe, and consider changes that might improve services and accelerate response to future challenges. Areas that need attention include minimisation of overintervention while responding to the changing disease burden. Conceptualisation, systematic measurement, and effective tackling of coverage and configuration challenges to implement high quality, respectful maternal health-care services are key to ensure that every woman can give birth without risk to her life, or that of her baby.

This is the third in a Series of six papers about maternal health. Show less